Psoriasis 2 Flashcards
Methotrexate
IND: Psoriasis and Arthritis
MOA: Folic acid antimetabolite that inhibits DNA synthesis, repair, and cellular replication
BOX: A LOT
CONTRA: Pregnancy, alcoholism, liver dz, immunodeficiency syndromes, blood dyscrasias
DOSE: Important in psoriasis. ONCE WEEKLY. Can be fatal if given more.
ADR: Increased LFTs causing hepatotoxicity. Bone marrow suppression. Alopecia. Photosensitivity. Supplement with daily folic acid except on the day they take Methotrexate to lessen ADRs.
MTX BOX WARNING
Monitor ADRs to ensure appropriate use
Can cause embryo fetal toxicity, don’t use in pregnancy
Severe, potentially fatal bone marrow suppression with NSAID use
Renal impairment
Hepatotoxicity
Pneumonitis; from MTX
GI toxicity can be severe and fatal; increased risk with NSAIDS
Risk of secondary malignancy (lymphoma), withdrawal of MTX may lead to regression
Tumor lysis syndrome
Dermatologic toxicity; potentially fatal after even a single dose
Opportunistic infections; can be fatal
Must be injected by an experienced physician
Cyclosporine
IND: Plaque psoriasis, immunosuppression for Tp pts, RA
MOA: Inhibit production and release of IL-2; inhibits activation of T cells
BOX: HTN/nephrotoxicity; dose and duration dependent, monitor and screen
Skin cancers; increased risk in pts treated with oral psoralens, MTX, UVA/UVB, coal tar, or other immunosuppressants
Increased risk of other infections and malignancies
Requires and experienced physician
CONTRA: Abnormal renal function, uncontrolled HTN, active malignancies. DISCONTINUE AT 6 WEEKS IF NO BENEFIT SEEN
ADR: HTN, hirsutism, increased Triglycerides, increased Serum creatinine, UTIs
Azathioprine
IND: Psoriasis, RA, Organ Tp rejection prevention
MOA: Halts DNA replication = halts cell division
BOX: Immunosuppression and increased risk of malignancy
ADR: Infection, leukopenia
Acitretin
IND: Severe psoriasis. Last line systemic therapy
MOA: Binds to and activates retinoid receptors; inhibits proinflammatory cytokines
BOX: Teratogenic. Avoid in pregnancy and for 3 years after treatment discontinuation
Do your PART: Pregnancy prevention Actively Required during and after Treatment
No blood donations for 3 years
Increased hepatotoxicity risk
CONTRA: Pregnancy and females of childbearing age unless in REMS program. Severe renal or hepatic dysfunction. Use with MTX. Hypertriglyceridemia.
ADR: A LOT.
Cheilitis
Alopecia
Hypertriglyceridemia
Adalimumab
IND: Psoriasis, RA, Crohn’s, other arthritis
MOA: DNA protein that contains TNF receptor, TNF binds to this, preventing it from binding it to the real ones = decreased role of TNF in inflammatory process
BOX: Serious infections development risk; hospitalization and death, more prevalent when on multiple immunosuppressants.
Increased prevalence of malignancies (lymphoma)
CONTRA: Sepsis
ADR: Injection site rxn. GI disturbance. Infections
Apremilast (oral)
IND: Moderate to severe plaque psoriasis
MOA: inhibits phosphodiesterase-4; increases levels of cAMP and regulation of inflammatory mediators
BOX: n/a
CONTRA: n/a
ADR: Weight loss via diarrhea/nausea. Expensive and new to market
M/E: Caution on CYP 3A4 Inhibitors AND inducers
Biosimilars
Not exactly the same as an FDA approved biologic agent
No clinically meaningful differences. Very rarely, pts have minute differences b/w the products.
NOT identical and therefore NOT generics
Utilize the generic name plus 4 letters with absolutely no meaning
Treatment Recommendations
Based on severity, comorbidities, cost/convenience, efficacy, and pt response
Desired outcome: maximum resolution and minimal skin involvement. 75% improvement or less than 3% skin involvement
5-10% BSA pt: systemic, topical isn’t practical. Biologic agents are more efficacious than oral systemic but also way more costly. May require failure before utilizing.
Mild/limited dz: responds well to topical corticosteroids and emollients/moisturizers.
Moderate/severe: Phototherapy or systemic therapies
Scalp Psoriasis: Consider different vehicles over ointment/cream
